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Don’t Shotgun

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Whether you are seeing patients in a student run clinic, or during your rotations, you will be ordering tests. How that is done, depends entirely on your site. The thing you need to be aware of is: WHY? Why are you ordering that CBC? Why are you ordering an ultrasound? You need to have a reason as to why these tests are being ordered. Your preceptors will ask, and expect an answer. If you do not have one, you will not only look bad, but you are doing yourself and your patients a disservice.

Now, let’s say you have a reason. Will it make a difference? Will the lab tests and/or imaging studies change your treatment? Because if it won’t, why are you doing it? Imagine you have a 30 year old female patient coming in with the complaint of dysuria, urinary urgency, and urinary frequency. This is a slam dunk for cystitis, so why are you ordering the urine analysis and culture? What will that tell you? That the patient has a UTI? You already know this patient has a UTI; the most likely cause is E coli, so give her the appropriate antibiotics. If you are unsure, you can do a dipstick, but anything more than that is a waste of time and money. This is a very simple example, but you get the point.

On a similar note, do not shotgun the treatment either! The worst example I’ve had was from a 36 year old female complaining of symptoms consistent with candidiasis: white thick discharge, pruritus, and dysuria. She went to a clinic in Mexico (where she was visiting family), and sought help. The patient had a pap smear done, and was given clotrimazole cream, fluconazole, ciprofloxacin, metronidazole, and triamcinolone ointment. One fluconazole tablet would have gotten the job done. Why was she given so much treatment? Well, it could have been a couple of things. It could have been the clinic trying to make more money (immoral), or the practitioner did not know how to work this patient up. I mean, I do not see any justification for ordering a pap smear, when the patient is there with candidiasis. The patient came in to see me 3 days into her treatment complaining of nausea and abdominal pain. Of course she was nauseous; look at what she was given! Needless to say, I stopped all her treatment, and advised to continue the clotrimazole.

Would this have treated the problem? Yes, but was it necessary? No. Make sure you know why you are ordering labs, and if they will change your management. Next, make sure you tailor your treatment appropriately. Patients often have a tough time completing their regimen. What this means is that if you can give a shorter duration of treatment, then do it. In the example above, give a course of antibiotics for three days, not seven. The cure rates are the same, but by increasing duration of treatment, you increase the risk of adverse reactions.

Obviously, this will take practice. In my opinion, those who practice medicine best are minimalists. They are the practitioners who can take a great history and do a great physical exam, and have the diagnosis. It’s the great clinician who is able to go straight to treatment without ordering $500 worth of labs and or a CT for every person coming in with abdominal pain. Try and practice this way with every patient. I still struggle with this, and I have to remind myself as to why I just ordered those labs. If you are conscious about this, and make an effort to be as much as a minimalist as possible, then you will become a great clinician!